MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 01,05,08 report with the FDA on 2014-04-04 for IVORY CLAMP 12A 50057348 manufactured by Heraeus Kulzer Llc.
[18706503]
Although we have not established that the device caused or contributed to the event, we're reporting it to be compliant with 21 cfr part 803 and out of an abundance of caution. Device breakage is addressed in the directions for use. The directions state, "do not place clamp in mouth until the rubber dam has been properly placed. Clamp could become a choking or safety hazard if dropped or broken in the mouth without proper use of the rubber dam at all times. Caution: modification, over-extending, bending, or use exceeding one year may cause breakage. " the assistant said that no one was injured during the incidence.
Patient Sequence No: 1, Text Type: N, H10
[18730401]
(b)(4) dealer emailed the complaint and office information. Called and spoke to a dental assistant in the office. The clamp broke as they were placing it on the tooth. It occurred few months ago. It would have been placed on the molar. No injuries occurred, but it was very startling for them and the patient when it broke. This was the first use of the clamp. She said she did not remember exactly which patient they were trying to use it on.
Patient Sequence No: 1, Text Type: D, B5
Report Number | 1925223-2014-00017 |
MDR Report Key | 3727326 |
Report Source | 01,05,08 |
Date Received | 2014-04-04 |
Date of Report | 2014-03-07 |
Date Mfgr Received | 2014-03-07 |
Date Added to Maude | 2014-06-02 |
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 |
Reporter Occupation | DENTAL ASSISTANT |
Health Professional | 3 |
Initial Report to FDA | 3 |
Report to FDA | 0 |
Event Location | 0 |
Manufacturer Contact | MS. AUDI BOGUCKI |
Manufacturer Street | 300 HERAEUS WAY |
Manufacturer City | SOUTH BEND IN 46614 |
Manufacturer Country | US |
Manufacturer Postal | 46614 |
Manufacturer Phone | 5742995409 |
Manufacturer G1 | HERAEUS KULZER, LLC |
Manufacturer Street | 300 HERAEUS WAY |
Manufacturer City | SOUTH BEND IN 46614 |
Manufacturer Country | US |
Manufacturer Postal Code | 46614 |
Single Use | 3 |
Previous Use Code | 3 |
Event Type | 3 |
Type of Report | 3 |
Brand Name | IVORY CLAMP |
Generic Name | CLAMP, RUBBER DAM |
Product Code | EEF |
Date Received | 2014-04-04 |
Model Number | 12A |
Catalog Number | 50057348 |
Operator | DENTAL ASSISTANT |
Device Availability | N |
Device Eval'ed by Mfgr | R |
Device Sequence No | 1 |
Device Event Key | 0 |
Manufacturer | HERAEUS KULZER LLC |
Manufacturer Address | 300 HERAEUS WAY SOUTH BEND IN 46614 US 46614 |
Patient Number | Treatment | Outcome | Date |
---|---|---|---|
1 | 0 | 2014-04-04 |