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May 19, 2016

Ms.

Re:

No:

Dear Ms. :

This patient was examined by me, at my South Orange office, on , 2016. This evaluation was arranged with the patient’s attorney, , Esquire, at your request.

IDENTIFYING INFORMATION:

Age: 60

Sex: Male

Address:

Employer at Time of Accident: Expedite Services, Truck Driver, 8 years

Present Employer: Same

Date of Accident:

Prior Accidents/Injuries/Surgeries: 2008 – MVA - L shoulder, back, denied any

head, face, mouth or jaw injuries

Subsequent Accidents/Injuries/Surgeries: 4/30/2016 – R leg injury

Prior TMJ Treatment: Denied

Dentist: 2000 – Present – Dr. Keith Bane in Jersey City

This patient recounts an accident in which he slipped on ice, landing face down on the steps of a truck. He describes trying to block his fall by extending his left hand and says that had he not blocked the fall, his injuries would have been worse.

Pointing to his upper left central and lateral incisors (#9 & 10), he reports they were both loosened in the fall. Additionally, he says the cap on his upper right first molar (#3) became loose and air was getting under it. He tells me the tooth, “wasn’t broken.”

He recalls being transported by ambulance to the emergency department of Jersey City Medical Center where stitches in his upper left lip were done. Presently, he complains of feeling a “lump” in the lip in the area of the laceration.

He also reports that he fractured multiple facial bones but says they did not require surgical repair.

January 2014,: on referral by his employer, he says he was examined by Dr. Berardo, an oral surgeon. He describes Dr. Berardo making him a flexible mouthpiece and instructing him to wear it on his upper teeth, “as much as I can.” He tells me he continues to use this device at nighttime.

Asked what other jaw pain treatment Dr. Berardo offereddid, he says the mouthpiece was the only treatment he got for the jaw pain. He states he did not have any jaw physical therapy and did not get any injections into jaw muscles.

When asked if he still has pain in his jaw, he tells me he does and reports that it limits the type of foods he is able to eat, restricting him to softer foods.

Asked to show me where the jaw pain is located, he points on the left side of his face below the left earlobe at the posterior border of his vertical jaw bone and on the side of his face. As I described this, he watched in a mirror and acknowledges that I accurately described the location of the pain. He tells me this is the same area that he initially showed Dr. Berardo.

Asked if he felt any change in how his bite fit together after the accident he answers, “I don’t remember.”

He describes hearing a “cracking noise” in his jaw and that it is associated with pain. When asked to show me where he feels that pain, he again points below his ear lobe at the posterior border of the vertical jaw bone and on the side of his face in the same area. He says he has pain in this area when he chews and when he pushes on it. He states, more

often than not, he has this pain but does not hear the cracking noise. butHe adds that when the cracking sound happens, it is associated with the pain and the same spot in line with the bottom of his earlobe.

He reports that his upper left central incisor (#9) and upper left lateral incisor (#10) were loosened when he fell and, again tells me, the cap that he had on his upper right first molar (#3) also became loose when he fell.

Because of the dental injuries he says he was referred to Dr. John Vitale, a general dentist. He remembers Dr. Vitale doing root canal treatments on the three teeth (#3, 9, 10). Then, because of ongoing pain associated with tooth #3, he says Dr. Vitale ultimately extracted the tooth. That was done about a year after having done the root canal treatment, he recalls.

He describes recounts that “right from the beginning” after the accident he had pain with the tooth #3. He says now that it has been extracted, he does not have pain in that area.

Discussing the upper left central and lateral incisors (#9 & 10), he says that after Dr. Vitale did the root canal treatments because of ongoing pain, he went back to Dr. Berardo who then did root end surgeries on both teeth. Asked if that surgery helped with the tooth pain (#9 & 10), he replies, “It didn’t change anything.” He continues telling me that these two teeth (#9 & 10) still hurt him. Just closing his teeth together or touching them (#9 & 10) with his tongue causes discomfort. But, when he bites into something like a sandwich with the two teeth (#9 & 10), he feels more than discomfort, “they cause pain.”

Then, pointing inside his mouth above the two teeth (#9 & 10), he describes having “a little numbness.” He says this is also present on the mucosa of the upper left lip. Additionally, he feels numbness on the skin of the left side of his nose to the area of the infraorbital foramen downward to the upper lip. The entire region, he tells me, feels “somewhat numb.”

Next, he complains that the crowns made by Dr. Vitale for teeth #9 & 10 are loose and that they have come out many times. “They both kept coming off. I went back and forth to the doctor at least six times, maybe more, to get the caps cemented over and over.” He says he would now like to see a different dentist.

He reports that Dr. Vitale wants to make a bridge in the upper right to replace the upper right first molar (#3), which was pulled after the failed root canal procedure. The patient, however, says, “He can’t fix the front teeth. I’m not going back to him.”

He again reports that he is only able to chew soft foods because of the jaw pain he feels on the left side, at the back of his jaw.

In this accident, he says he also hurt his back but reports that now, “It’s okay.”

When asked if we have covered basically everything pertaining to his face, mouth or jaw, he replies, “Yes.”

The aforementioned history was dictated, added to and corrected in the presence of the patient.

CLINICAL EVALUATION:

1. DENTAL:

The entire examination was done using non-latex gloves.

This patient is missing nine teeth: upper right third, first molars (#1, 3), upper left third molar (#16), lower left three molars (#17, 18, 19), lower right three molars (#30, 31, 32).

(Please see attached TOOTH CHART.)

The lower left second bicuspid (#20) has drifted distally and is rotated.

The lower left lateral incisor (#23) is rotated.

The upper left central and lateral incisors (#9, 10) are restored with porcelain fused to metal crowns. There isis 2+ mobility of the crown on tooth #9 and 1+ mobility of the crown on tooth #10. With percussion of these crowns, the patient has a jump response. Application of topical anesthetic did not cause the patient to change his complaint of pain in area.

Periodontal status is satisfactory.

There is a Class I occlusion on right and left sides.

There is a vertical overbite of 5mm and a horizontal overjet of 4mm.

There are no anterior or posterior open bites and no anterior crossbites present. There are posterior right and left posterior crossbites present. Right side: between teeth #4, 5 and #28, 29. Left side between teeth #12, 13 and #20, 21.

There is a scar on the upper left lip. The patient is reactive to palpation of this scar.

There is no mandibular soft tissue midline discrepancy in centric occlusion.

There are no significant facial asymmetries. Ramus height is equal.

2. CRANIOMANDIBULAR:

Joint palpation was performed. There was no swelling in either jaw joint. There was no report of tenderness or pain to palpation of the lateral and posterior walls of the right jaw joint, and no pain to palpation of the posterior wall of the left jaw joint. There was mild response to palpation of the lateral wall of the left jaw joint.

Mandibular range of motion was measured. Maximum unassisted, pain free interincisal opening was 37mm plus 5mm vertical overbite (total = 42mm). The patient was next asked to open as wide as he possibly could. This time, he opened 43mm plus 5mm vertical overbite (total = 48mm). This too was performed without deviation or deflection but with reported discomfort in the left masseter. Maximum active opening after spraying with vapocoolant was 45mm plus 5mm vertical overbite (total = 50mm) with no reported discomfort. Maximum unassisted protrusive movement brought mandible into an edge to edge relationship with upper anterior teeth. With the 4mm horizontal overjet, total protrusive movement was 4mm. This was performed without deviation, deflection or reported discomfort or facial expression suggestive of discomfort. Maximum right lateral excursion was measured at 8mm, performed without reported discomfort. Maximum left lateral excursion was measured at 8mm, performed without discomfort. All jaw movements were active movements and performed by the patient without assistance.

Joint auscultation with a stethoscope for assessment of internal joint sounds was performed. There was no crepitation and no palpable crepitation. There is a late closing click on the right side. On the left, there is a late opening, early closing click. No joint noises were heard with manual joint loading or with side to side jaw movements. The noises did occur on both sides when the patient chewed on a moist cotton roll.

Functional tests were performed. The patient was asked to chew on a moist cotton roll. This test demonstrates masticatory function and endurance and was performed while a stethoscope was held to the patient’s jaw joints to listen for joint sounds. The patient was instructed to chew, first, on the right side while I first listened to the right jaw joint for one minute and then listened to the left jaw joint for another minute. This same process was repeated while the patient chewed on the left side. The patient chewed for four minutes at a functional pace without hesitation. While he chewed on the right, after about one and

a half minutes, he complained of left masseter muscle pain. He continued to chew, however, without any decrease in his chewing pace. When he moved the cotton to the left side, his right jaw joint made repeated snapping noises. However, when asked if it hurt him he answered, “No, it hurt over here” and pointed to his left masseter muscle area.

Elevating the lower jaw manually by pressing the condyles upward and backward, in order to increase the internal joint load, caused him to report discomfort in the left jaw joint.

Functional tests to provoke the lateral pterygoid muscles were performed. There were no responses consistent with lateral pterygoid muscle pain.

When asked to clench his teeth together, the patient had no complaints related to the jaw joints or masticatory muscles.

All functional tests involved only active movements made by the patient without assistance.

With cranial nerve screening, the patient reported decreased sensation on the left in Division 1 of the fifth cranial nerve to cotton wisp testing, and decreased sensation on the left in Division 2 of the fifth cranial nerve to cotton wisp and sharps testing, specifically in the left infraorbital area. This may warrant further evaluation.

Palpation of masticatory and cervical musculature was subjectively reported as tender in the following:

Left: Superficial Masseter Body * radiates up & down

Deep Masseter *

Stylomandibular Ligament * radiates to cheek

Suboccipitals *

Medial Pterygoid

Temporalis Insertion

( * = indicates possible trigger point)

3. RADIOGRAPHIC:

A panoramic radiograph, as well as periapical radiographs, were taken as part of the evaluation of this patient. These x-rays do not reveal any evidence of fracture or growth abnormalities. There is a radiolucent area around the apical aspect of tooth #10. This may be residual from apicoectomy surgery.

There are root canal treatments and post and cores, as well as apicoectomies in teeth #9 and #10. The patient estimates the apicoectomies were done in the summer of 2015. There are root canal posts in both teeth.

Transcranial radiographs consisting of open and closed projections of both temporo-mandibular joints were taken. The articular surfaces of the joints are normally smooth and consistent. The eminence on both right and left sides appears to be of similar steepness. This film was taken to aid in interpretation of joint function by comparing the position of the condyles in the closed and opened mouth positions. Both condyles were noted to translate to the height of the articular eminence, consistent with a nonrestricted range of motion of the lower jaw.

DISCUSSION:

The patient’s entire history and examination was conducted by me.

This patient recounts an accident in which he slipped on ice and fell, hitting his face on the ground.

He was taken to Jersey City Medical Center where he was diagnosed with laceration of his left cheek and left upper lip, as well as multiple facial bone fractures including "fracture of the left orbital floor with minimal downward displacement of the fracture fragments…minimally displaced fracture of the left posterolateral maxillary sinus wall." He denied any loss of consciousness.

January 10, 2014, one month after the subject accident, he was evaluated by Dr. Nicholas Berardo, an oral surgeon. I was sent handwritten notes from Dr. Berardo that are essentially indecipherable. In his February 7, 2014, typed report, Dr. Berardo wrote, "Mandibular [opening] was noted to be 36 mm with left-sided preauricular pain and clicking at approximately 18 mm of opening. Maximal opening could continue to 42 mm. Excursions were noted to be 12-13 mm with left-sided click and left-sided preauricular pain."

The American Academy of Orofacial Pain published their annual 2013Orofacial Pain: Guidelines for Assessment, Diagnosis, And Management of Orofacial Pain (Orofacial Pain, 2013 Quintessence Publishing Co., pg. 34) which describes the normal mandibular range of motion: “Normal mandibular opening is estimated as ranging from 40 to 55 mm, whereas excursive movements of at least 7 mm are considered normal."

Just a month after the accident, when he met with Dr. Berardo, the patient’s total mouth opening was 42 mm, too wide an opening to conclude that he had sustained a traumatic internal derangement of his temporomandibular joint in the accident.

Further supporting the conclusion that this accident did not produce any clinically significant internal jaw joint injury is the fact that the patient’s side-to-side lateral excursions were measured by Dr. Berardo at 12-13 mm. These, according to the AAOP range of motion measurements, are relatively large lateral movements that are, again, not consistent with a recent traumatic internal jaw derangement.

If this accident had caused an internal derangement in the left temporomandibular joint, the patient would have had a markedly limited lateral movement toward his right side. But, in this case, Dr. Berardo wrote, "Excursions were noted to be 12-13 mm with left-sided click and left-sided preauricular pain." The left sided preauricular pain was from muscle pain —not joint pathology.

Additionally, there was no report of the patient complaining of an acute shift in the way his bottom teeth fit against his top teeth. When I asked him if after the accident he felt a change in the fit of his bite, he told me he did not remember. If this accident had produced internal joint trauma of such magnitude that it resulted in structural changes in the jaw joints, there would have been internal joint swelling. That swelling would have caused the condylar head to be displaced. As a result of that condylar displacement, the position of the lower jaw would have been slightly shifted with a resultant, unmistakable change in how the lower teeth fit against the upper teeth. I do not believe any patient, including this patient, could overlook such an alteration in the bite. In the absence of such bite alteration, I do not accept that there was any injury to the structures within the temporomandibular joints.

Dr. Berardo did describe there being "myospasm of the left temporalis tendon and pterygoid muscles." I do accept that the patient’s jaw muscle pain could have been caused by the subject accident.

When I examined him, I found him to have probable trigger point formation in his left superficial and deep masseter muscles as well as in the left stylomandibular ligament.

The patient told me the only jaw pain treatment he got from Dr. Berardo was an oral appliance. He did not get trigger point injections, and he was not referred for physical therapy. This pain would be expected to significantly improve if he were to undergo this type of treatment.

Interestingly, after wearing the soft oral appliance from Dr. Berardo for a week, on January 16, 2014, the patient’s mouth opening increased to 40 mm, a 4 mm improvement from a week earlier and, according to the American Academy of Orofacial Pain, a full and normal mouth opening.

I was not sent the operative report, but it appears Dr. Berardo surgically did an open exploration of the left infraorbital rim fracture and decompression of the left infraorbital nerve at the infraorbital foramen. Among the patient’s current complaints is altered sensation on the left side of his face in the distribution of the left infraorbital nerve. Assessment of this complaint is outside the scope of dentistry.

Dr. Berardo also indicated that he did a revision of the left lower lip scar. I assume he meant upper lip. The patient reported having discomfort with palpation of this scar. Assessment of this is outside the scope of dentistry.

April 24, 2014: the patient was referred to Dr. John Vitale, a dentist, who wrote, "The patient was referred to my office to have teeth #'s 9, 10, and 3 evaluated for root canal therapy." It should be noted that Dr. Berardo discussed trauma to teeth #9, 10, and 11. There was no mention of tooth #3. The patient told me the tooth (#3) had a prosthetic crown that got loosened. It is hard to accept that trauma to his left face could cause the cement seal holding the crown onto the tooth to loosen. Nevertheless, giving every benefit of the doubt, I accept the treatment done for tooth #3 as accident related.

I did not receive Dr. Vitale’s treatment records and do not know why he needed to do the root canal treatment for the patient’s upper right first molar (#3); however, after the root canal treatment and after a root end surgery with Dr. Berardo, the patient had to have the tooth (#3) pulled. He is entitled to the statutory amount for the loss of 1 natural tooth (#3).

Replacement of tooth #3 would best be done with a dental implant if it can be done without needing a sinus lift surgery. This assessment will call for a Cone Beam CT scan evaluation. If the implant cannot be done without sinus surgery, it would be reasonable to do a 3-unit bridge extending from the upper right second molar (#2) to the upper right second bicuspid with a pontic in the position of the missing upper right first molar (#3).

I was sent photocopies of Dr. Vitale's x-rays making them difficult to read; however, it appears on the x-ray dated May 5, 2014, that there was a crown on tooth #3 and possible decay at the distal margin. Please provide original prints of these x-rays which will make diagnosis easier.

Again, it is extremely difficult to decipher Dr. Berardo's handwriting, but it appears after Dr. Vitale completed the root canal procedures the patient had ongoing issues with the teeth so Dr. Berardo did root end surgeries (apicoectomies) on teeth #3, 9, and 10.

Today, the patient told me that he has no pain in the extraction site area of tooth #3, but he still has pain related to teeth #9 and 10. This patient should have diagnostic local anesthetic infiltration blocks done above these two teeth (#9 & 10) to determine if the local anesthetic shuts off the pain. Assuming that it will, then the patient’s pain can be assumed to be from the teeth. If it does not shut off the pain, then the pain may be coming from where the nerve travels in the fracture area.

If the patient’s tooth pain (#9 & 10) can be stopped by local anesthetic blocks, then these two teeth (#9 & 10) should be extracted and replaced with dental implants and implant supported crowns.

Consistent with the patient’s report to me that the crowns on teeth #9 & 10 are loose, I found both to be somewhat mobile with palpation. He told me he has been back to Dr. Vitale at least 6 times to get the crowns recemented. As a consequence, he reported that he has lost confidence in the doctor and will not return to him.

Under these circumstances, I recommend he be referred to Dr. Fariba Farrokhi who can address both the dental issues and his temporomandibular pain issues.

If teeth #9 and 10 need to be extracted and replaced with implants, I recommend the patient be referred to Dr. Barry Wagenberg in Livingston. Dr. Wagenberg is a periodontist with great expertise in implant surgery.

SUMMARY:

1. The patient’s entire history and examination was conducted by me. This evaluation took 1½ hours.

2. Please provide the following records:

- treatment records and diagnostic quality x-rays from Dr. Vitale

- emergency room records

- dental records from 2010 until present time from the patient’s general dentist, Dr. Keith Bane.

3. The patient reported having discomfort with palpation of his upper left lip scar. Assessment of this is outside the scope of dentistry.

4. This accident did not produce an internal derangement of either temporomandibular joint.

5. The patient’s left side jaw muscle pain should be treated using trigger point injections and/or masseteric nerve blocks.

6. He is entitled to the statutory amount for the loss of 1 natural tooth (#3).

7. A CT scan of the area of tooth #3 should be done to determine if a dental implant can be placed without needing a sinus lift.

8. If sinus surgery is needed for tooth #3, then the missing tooth can be replaced with a 3-unit bridge extending from #2 to #4.

9. Local anesthetic blocking above teeth #9 & 10 should be done to determine if the pain in this area can be shut off. If it can be shut off, then these two teeth should be pulled and replaced with dental implants.

10. The patient’s left side masseter muscle and stylomandibular ligament pain should be treated with trigger point injections and/ or nerve blocks. A hard acrylic oral appliance may be needed.

11. Treatment of his jaw pain should be done before any more restorative dental treatment.

12. The patient does not want to return to Dr. Vitale. I recommend he be referred to Dr. Fariba Farrokhi in South Orange. Dr. Farrokhi can treat his jaw pain and provide the restorative dental needs.

13. I recommend referral of the patient to Dr. Barry Wagenberg in Livingston for assessment and placement of dental implants.

14. Determination of residual disability, if any, must be delayed until treatment is completed.

The following records were provided to and reviewed by me:

If you wish the medical records returned, please notify this office in thirty days or they will be destroyed.

Respectfully submitted,

James E. Chenitz, D.M.D.

JEC/sg Dictated but not proof read

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