BEUDAMED
    FDA Adverse Event Injury Summary report: N

    SMILEDIRECTCLUB ALIGNER SYSTEM

    MDR report key: 12368698 · Received August 25, 2021

    Report

    Report Number
    3014658399-2021-00052
    Event Type
    Injury
    Date Received
    August 25, 2021
    Date of Event
    July 26, 2021
    Report Date
    September 2, 2021
    Manufacturer
    ACCESS DENTAL LAB
    Product Code
    NXC
    PMA / PMN Number
    K191990
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 0

    ADDITIONAL MANUFACTURING INFORMATION PROVIDED SINCE IT WAS NOT AVAILABLE AT THE TIME OF INITIAL SUBMISSION, SECTION (D4).

    Additional Manufacturer Narrative · 1

    BASED ON THE INFORMATION PROVIDED BY THE PATIENT AND INTERNAL INVESTIGATION CONDUCTED BY ACCESS DENTAL LAB, THERE IS NO CONCLUSIVE EVIDENCE THAT SUPPORTS OR OPPOSES THE FACT THAT THE ALIGNERS CAUSED, CONTRIBUTED, OR WOULD LIKELY CAUSE OR CONTRIBUTE TO THE REPORTED EVENT. THIS EVENT IS BEING FILED AS AN MDR SINCE THE PATIENT REPORTED SYMPTOMS OR PHYSIOLOGICAL CONDITIONS THAT DESCRIBE TOOTH (BREAKAGE) FRACTURE.

    Description of Event or Problem · 1

    THE CUSTOMER REPORTED THAT DUE TO WEARING ALIGNERS TOOTH #4 HAS BROKEN. NO MEDICAL INTERVENTION WAS REQUIRED. AS A RESULT, ALIGNER TREATMENT WAS DISCONTINUED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1265150 SMILEDIRECTCLUB ALIGNER SYSTEM SEQUENTIAL ALIGNER NXC ACCESS DENTAL LAB N/A N/A

    Patients

    Seq Age Sex Outcome Treatment
    1 36 YR Other