RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01175
BRANCH OF SERVICE:  Army	                        SEPARATION DATE:  20090429

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Motor Transport Operator, medically separated for “pain with limited motion of left temporomandibular joint,” with a 10% disability rating.  

CI CONTENTION:  The CI elaborated no specific contention in his application.  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20080923	VARD -20090129  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Limited Motion of Temporomandibular Articulation…	9905	10%	Temporomandibular Joint Dysfunction Left Jaw,
Postoperative	9905	20%	20081008	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA RATINGS:  20%	

ANALYSIS SUMMARY:  

Limited Motion of Temporomandibular Articulation.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s temporomandibular joint (TMJ) condition began in 2003 following a dental procedure that caused dislocation of his jaw.  Following this procedure the CI experienced persistent pain and tenderness of the jaw.  He was given a mouth guard and deployed in December 2003.  During deployment the CI was involved in an improvised explosive device incident and hit his head, which caused left TMJ displacement and the CI reported being unable to open his mouth at the time.  The CI underwent two surgical procedures for the TMJ condition, one at a civilian medical facility in 2005 (after separation from active duty) and one at the VA in 2006.  At the VA Compensation and Pension (C&P) examination on 27 November 2007, 14 months before separation (further summarized below), the CI reported the same chronic jaw symptoms.  Despite treatment, the TMJ condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “internal derangement of the left temporomandibular joint (TMJ) with adhesive capsulitis and synovitis” for PEB adjudication.

At a dental clinic evaluation on 29 July 2008, 6 months before separation, the CI reported daily pain with chewing or talking.  He graded the pain interference in daily activities as 2/10.  He reported left temporal region headaches a few times per week, relieved by over the counter anti-inflammatory medication.  The physical examination noted tenderness to palpation (TTP) of the left TMJ and jaw muscles, with jaw deviation to the left with opening, without crepitus.  The inter-cisal opening (mouth opening) was 30mm comfortably, and 40mm maximum with right and left lateral excursion of 5mm each.
 
The MEB examination (recorded on DD Forms 2807 and 2808) dated 30 July 2008 noted the CI was wearing a mouth appliance and the inter-cisal distance was recorded as 35mm.

At the MEB NARSUM examination on 30 July 2008, the CI reported chronic pain and limited motion of his jaw, with difficulty eating hard foods or wearing Kevlar.  The MEB physical examination noted normal evaluation of the head, ears, eyes, nose, throat and neck.  Cranial nerves were intact.  The CI was wearing a mouth guard.  The inter-cisal ROM and lateral excursion was the same as noted at the dental examination above.

At the VA Compensation and Pension (C&P) examination on 27 November 2007, 14 months before separation, the CI reported the same chronic jaw symptoms.  He reported an episode in August 2007 where the joint dislocated and he required medical treatment at the VA to have it reduced.  The physical examination showed a well healed surgical scar that did not limit ROM.  There was TTP of the TMJ and related muscles.  The jaw was deviated 2mm to the right and the maximum opening was 27 mm, with 6 mm right later excursion and 3mm left lateral excursion.  Dental X-rays showed loss of the joint space and cartilage.

At the VA Compensation and Pension (C&P) examination on 8 October 2008, 3 months before separation, the CI reported the same chronic symptoms and noted that the ROM of his jaw had worsened.  There was TTP and the jaw was deviated to the right by 2 mm.  The maximum opening was 24mm, with 4mm right lateral excursion and 6 mm left lateral excursion.  There was no crepitus noted.  Dental X-rays showed loss of articular cartilage with bone to bone contact in the left TMJ.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the TMJ condition 10%, coded 9905 (limited motion of TMJ).  The original VA Rating Decision in January 2007 did not service connect the TMJ condition due not having medical records available.  The VARD dated 8 November 2007 rated the TMJ condition 10%, also coded 9905, based on service medical records and VA treatment reports.  The VARD dated 21 December 2007 increased the rating to 20% (9905), based on the November 2007 C&P examination.  The VARD dated 29 January 2009 continued the 20% rating, coded 9905, after the October 2008 C&P examination summarized above.  The evidence at the dental evaluation and MEB (DD From 2808) in July 2008 support a 10% rating coded 9905, however, a 20% rating is supported by the C&P examination closest to the date of separation.  The Board determined that in this case, the CI was noted to have severe TMJ joint damage and pathology that was consistent with the findings at the two C&P examinations noted above.  The CI had muscle and joint tenderness likely associated with muscle spasm at times and the jaw ROM was noted to frequently be sufficiently limited to warrant the 20% rating.  The Board also considered if a higher rating was available with any applicable VASRD §4.150 code.  There was no malunion, nonunion, or loss of the mandible, or osteomyelitis/osteonecrosis to warrant consideration under the respective codes (9904, 9903, 9902, 9901, 9900).  Therefore, with consideration of VASRD §4.7 (Higher of two evaluations), the Board determined a 20% rating is supported in this case and no higher.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left TMJ condition.  

BOARD FINDINGS:  In the matter of the left TMJ condition, the Board unanimously recommends a disability rating of 20%, coded 9905 IAW VASRD §4.150.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Limited Motion of Temporomandibular Articulation	9905	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140304, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160011457 (PD201401175)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA