Citation Nr: 18156542 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-60 602 DATE: December 11, 2018 ORDER Service connection for top jaw injury with dentofacial deformity, bilateral, is denied. FINDING OF FACT The Veteran does not have a dental disability for VA compensation purposes. CONCLUSION OF LAW The criteria for entitlement to service connection for top jaw injury with dentofacial deformity, bilateral, have not been met, and the payment of disability compensation is precluded by law. 38 U.S.C. §§ 1110, 1712, 5107, 7104(c); 38 C.F.R. §§ 3.102, 3.159, 4.150. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from April 2005 to December 2012. 1. Service connection. The Veteran argues that he is entitled to service connection for “top jaw injury with dentofacial deformity bilateral.” See VA Form 646, dated in November 2017. The Board first notes that service connection is currently in effect for disabilities that include status post right nasal fibroma excision, and scar, status post septorhinoplasty. There are also notations in VA progress notes indicating that the Veteran has been found to be eligible for Class II dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. § 17.161. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, when “all of the evidence, including that pertinent to service, establishes that the disease was incurred during service.” See 38 C.F.R. § 3.303 (d). Dental disabilities which may be awarded compensable disability ratings are now set forth under 38 C.F.R. 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Rating activity should consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. 38 C.F.R. § 3.381 (b). For loss of the teeth, bone loss through trauma or disease, such as osteomyelitis, must be shown for compensable purposes. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by suitable prosthesis. Id. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease (pyorrhea) are not disabling conditions. See 38 C.F.R. § 3.381. The term “service trauma” does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran’s active service. See 38 C.F.R. § 3.306 (b)(1); VAOGCPREC 5-97, 62 Fed. Reg. 15,566 (1997). However, the United States Court of Appeals for the Federal Circuit has elaborated that an unintended result of medical treatment due to military negligence or malpractice could be “service trauma” pursuant to 38 U.S.C. § 1712 (a)(1)(C). Neilson v. Shinseki, 607 F.3d 802 (Fed. Cir. 2010). Overall, the Board first notes that the Veteran’s service treatment records contain multiple entries regarding dental care that are somewhat difficult to read; the Board has discussed the ascertainable and relevant findings below. In April 2005, upon entrance into service, the Veteran reported having had had two wisdom teeth removed. See Health Questionnaire for Dental Treatment (HQST), dated in April 2005. In August 2007, the Veteran sought treatment for complaints of severe pain and popping of his TMJ (temporomandibular joints). He was noted to have a Class III malocclusion. He was advised to quit chewing gum and to apply heat, and that more definitive care may involve surgery. A December 2007 report notes use of a splint, with improved symptoms. An initial patient questionnaire, dated in May 2008, shows that the Veteran complained of a history of popping in the left side of his mouth since 2006, with difficulty chewing and opening his mouth. He reported having used a mouth piece. He rated his pain as a “6” out of “10,” with 10 being the most severe. He also reported locking and clinching. He denied a history of whiplash or trauma to his head or neck. In June 2008, the Veteran was evaluated for his jaw symptoms. He was noted to be under evaluation for surgery and to correct skeletal Class III joint problems with maxillary deficiency. The report indicates that surgery was discussed and that the Veteran elected to receive surgical care, even though it may not totally alleviate his problems. A January 2009 report notes that the Veteran’s teeth were ligated with steel, prior to his deployment. See also February 2009 notation. A HQDT, dated in January 2010, does not note any relevant symptoms, complaints or conditions. A May 2010 dental chart appears to note that teeth #1, #5, #12, #16, #17, #21, #28, and #32 are missing. An operative report, dated in August 2010, shows the following: The Veteran was hospitalized for two days. He was noted to have been in a combined treatment plan with orthodontic and orthognathic surgery for correction of dental facial deformity. The Veteran underwent a LeForte I advancement osteotomy. The pre- and postoperative diagnoses were maxillary hypoplasia with asymmetry. There was a primary discharge diagnosis of dentofacial deformity. Dental X-rays are of record, dated in August 2010. Post-surgery reports, dated in August 2010, note complaints of numbness. He was noted to have normal healing. The diagnosis was LeForte I advancement one week ago with good result. A September 2010 dental report notes complaints of mild numbness and pain in the upper lip area. The Veteran was noted to be status post LeForte surgery one month earlier with good result. A December 2010 report shows that the Veteran reported being happy with the result of his surgery. The report appears to note a complaint of mild pain and Class I occlusion. See also October 2010 report (noting Class I occlusion). The diagnosis was status post LeForte advancement August 2010 with possible development of nasal polyps in right nostril area. The Veteran received follow-up treatment for bleeding of his right nostril in January 2011. A January 2011 report notes plate and screw fixation devices are noted on sinus X-ray, at the maxilla, specifically in the anterior wall of the bilateral maxillary sinuses. A March 2011 report notes that a dental examination was negative, and that there were no complaints. The Veteran was noted to be healing normally, with an “excellent result.” There were multiple findings in 2011 noting that pain was characterized as “0/10.” A HQDT, dated in April 2011, does not note any relevant symptoms, complaints or conditions. There is also a finding, dated in April 2011, that the Veteran’s soft tissues were WNL (within normal limits). A report, dated in July 2011, is difficult to read, but appears to note an asymptomatic lesion at the right floor of the mouth. The assessment notes minor irritation with no pathology identified. A HQDT, dated in June 2012, notes a history of jaw surgery. A periodic oral evaluation, dated in June 2012, notes that the soft tissues were within normal limits. The Veteran’s separation examination report, dated in about July 2012, shows that his mouth and throat were clinically evaluated as normal. In an associated report of medical history, he denied a history of severe tooth or gum trouble. He reported having had plates put into his cheek area in 2011, or 2012, and a history of jaw and nose surgery. A VA disability benefits questionnaire (DBQ), dated in December 2012, by R.S., DDS, notes that the Veteran reported the following: The Veteran was involved in a IED (improvised explosive device) explosion in 2009. The Veteran reported that he did not receive any major injuries to his face at that time. The Veteran was subsequently noted to have a deficiency in the maxilla, bilaterally. This gave him an overbite, with his maxilla being protruded. The Veteran underwent a LeForte surgery in August 2010, with the maxillary segments being advanced after orthodontics. The Veteran has a pain level of approximately 1, and he does not take any medication to manage the pain. On examination, there was no tooth loss due to loss of substance of body of maxilla or mandible (other than loss due to periodontal disease). There was no loss of motion. There was no loss of bone of the maxilla. The Veteran presented with his third molars removed, along with his first premolars, which had been removed for orthodontic reasons. The Veteran had a maximal incisal opening of 54 millimeters (mm.) with repetitions of threes. The Veteran felt a slight pull on the left side, but no real pain. His right, left, and protrusive movements were 7 mm., 7 mm., and 6 mm., respectively. No pain was noted on the excursions. No bone loss was noted radiographically. The Veteran sat for a Panorex; no abnormality was found in the TMJ (temporomandibular joint), which suggests that the Veteran has a normal TMJ bilaterally. There were chains and plates placed in the maxilla that correspond with maxillary advancement. Other than the plates, no other conditions were noted. The examiner noted that given the Veteran’s report that he did not sustain any injuries from the IED blast, his bilateral maxilla deformities were corrected with surgery. The examiner noted, “Everything seems to be in fairly good working order at this point in time, and that since there were no major problems with the teeth, it is not likely that an injury to the face was the cause of the Veteran’s surgery. In an addendum, dated in September 2013, Dr. R.S. states: The patient’s C&P (compensation and pension) file was reviewed. No findings were outside what was already discussed in the first C&P (i.e., the December 2012 DBQ). The patient had a facial abnormality consisting of a retruded maxilla. The patient subsequently underwent maxillary advancement successfully with no other problems noted. VA progress notes include a report, dated in May 2015, which notes treatment for a possible inflammatory response to rigid fixation plates and screws. The examiner stated this may be a stitch abscess related to his septoplasty. There was a diagnosis of adjunctive procedure. Reports, dated in October and December of 2015, show that the Veteran denied having dental problems that affected his eating. The Board finds that the claim must be denied. It is clear that the Veteran underwent a LeForte I advancement osteotomy in August 2010. The pre- and postoperative diagnoses were maxillary hypoplasia with asymmetry, and there was a primary discharge diagnosis of dentofacial deformity. However, there is no evidence to show that the Veteran sustained an unintended result of medical treatment due to military negligence or malpractice due to his treatment. Neilson v. Shinseki, 607 F.3d 802 (Fed. Cir. 2010). The Veteran is not shown to have been a prisoner of war. There is no evidence to show that the Veteran has one of the dental disorders listed under 38 C.F.R. § 4.150, and there is therefore no basis for an award of compensation based on the Veteran’s claim. Limited temporomandibular motion is not shown. See 38 C.F.R. § 4.150, Diagnostic Code 9905. Given the foregoing, the evidence does not show that the Veteran sustained compensable “dental trauma” in service. As the Veteran does not have a compensable dental disorder, there is no basis for an award of compensation based on the Veteran’s claim. In reaching this decision, the Board has considered the Veteran’s assertions. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T.S.E., Counsel