MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05 report with the FDA on 2013-05-06 for HERBST manufactured by Allesee Orthodontic Appliances.
[3164511]
A doctor's office alleged that while removing the herbst appliance a patient had experienced the loss of a crown, which had attached to it an amalgam restoration and some of the patient's natural dentition.
Patient Sequence No: 1, Text Type: D, B5
[10687899]
A new crown was placed for the patient by a dentist, without further incident. To date, the patient is doing fine and has fully recovered. A new appliance will be fabricated with consideration to patient comfort. A visual evaluation was performed on the returned device, yielding results within specifications.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 2184045-2013-00005 |
| MDR Report Key | 3093893 |
| Report Source | 05 |
| Date Received | 2013-05-06 |
| Date of Report | 2013-04-16 |
| Date Mfgr Received | 2013-04-16 |
| Date Added to Maude | 2013-05-06 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | MRS. KERRI CASINO |
| Manufacturer Street | 1717 W COLLINS AVE |
| Manufacturer City | ORANGE CA 92867 |
| Manufacturer Country | US |
| Manufacturer Postal | 92867 |
| Manufacturer Phone | 7145167634 |
| Manufacturer G1 | ALLESEE ORTHODONTIC APPLIANCES |
| Manufacturer Street | 13931 SPRING STREET |
| Manufacturer City | STURTEVANT WI 53177 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 53177 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | HERBST |
| Generic Name | BITE-JUMPING ORTHODONTIC APPLIANCE |
| Product Code | EJF |
| Date Received | 2013-05-06 |
| ID Number | WO #7407415 |
| Operator | OTHER |
| Device Availability | Y |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | ALLESEE ORTHODONTIC APPLIANCES |
| Manufacturer Address | 13931 SPRING STREET STURTEVANT WI 53177 US 53177 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other; 2. Required No Informationntervention | 2013-05-06 |